Medicare Value-Based Purchasing for Physicians' Services Act of 2005 - Amends part B (Supplementary Medical Insurance) of title XVIII (Medicare) of the Social Security Act to provide for value-based purchasing in the payment for physicians' services under the Medicare program. Establishes updates to the single conversion factor for 2006 through 2009 and succeeding years for such services.
Directs the Secretary of Health and Human Services to: (1) provide, as part of the rulemaking process, for the selection of quality measures (Q-measures) and efficiency measures (E-measures) meeting specified general requirements; and (2) determine a single rating of each billing unit based on Q and E measures, and disclose to the public whether a particular billing unit met performance objectives.
Requires the Secretary to establish such performance objectives, and base upon them any increased updates in the payment for physician services.
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3617 Introduced in House (IH)]
109th CONGRESS
1st Session
H. R. 3617
To amend part B of title XVIII of the Social Security Act to provide
for value-based purchasing in the payment for physicians' services
under the Medicare Program, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 29, 2005
Mrs. Johnson of Connecticut (for herself, Mr. Beauprez, Mr. Boustany,
Mr. Burgess, Mr. Camp, Mr. English of Pennsylvania, Mr. Gingrey, Mr.
Sam Johnson of Texas, Mr. Lewis of Kentucky, Mr. Ney, Mr. Ramstad, Mr.
Shaw, Mr. Shays, Mr. Upton, Mr. Weldon of Florida, and Mrs. Kelly)
introduced the following bill; which was referred to the Committee on
Energy and Commerce, and in addition to the Committee on Ways and
Means, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend part B of title XVIII of the Social Security Act to provide
for value-based purchasing in the payment for physicians' services
under the Medicare Program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicare Value-Based Purchasing for
Physicians' Services Act of 2005''.
SEC. 2. VALUE-BASED PURCHASING FOR MEDICARE PHYSICIANS' SERVICES.
(a) Link of Value-Based Purchasing to Payment for Services.--
Subsection (d) of section 1848 of the Social Security Act (42 U.S.C.
1395w-4) is amended--
(1) in paragraph (1)(A), by inserting ``and before 2006''
after ``beginning with 2001'';
(2) in paragraph (1)(A), by inserting before the period at
the end the following: ``, and for years beginning with 2006,
multiplied by the update established under paragraph (6) or a
succeeding paragraph, as is applicable to the year involved'';
(3) by adding at the end the following new paragraphs:
``(6) Update for 2006.--The update to the single conversion
factor established in paragraph (1)(C) for 2006 shall be 1.5
percent.
``(7) Update for 2007 and 2008.--
``(A) In general.--Subject to subparagraphs (B) and
(C), the update to the single conversion factor
established in paragraph (1)(C) for 2007 and 2008 shall
be the percentage increase in the MEI (as defined in
section 1842(i)(3)) for the year involved minus 1
percentage point.
``(B) Increase for submitting information.--In the
case of physicians' services furnished by a billing
unit under this part that is a new billing unit (as
defined by the Secretary) or that complies with the
requirement of subsection (k)(4) for the submission of
information for 2007 or 2008, the update to the single
conversion factor established in paragraph (1)(C) for
the year shall be the percentage increase in the MEI
(as defined in section 1842(i)(3)) for the year
involved.
``(C) Treatment.--In computing the single
conversion factor under paragraph (1)(C)--
``(i) for 2008, the update for 2007 shall
be treated as the update described in
subparagraph (B); or
``(ii) for 2009 or a succeeding year, the
updates for 2007 and 2008 shall be treated as
the updates described in subparagraph (B).
``(8) Update for 2009 and succeeding years.--
``(A) In general.--Subject to subparagraphs (B) and
(C), the update to the single conversion factor
established in paragraph (1)(C) for 2009 and each
succeeding year shall be the percentage increase in the
MEI (as defined in section 1842(i)(3)) for the year
involved minus 1 percentage point.
``(B) Increase for submitting information and
meeting quality and efficiency standards.--In the case
of physicians' services furnished by a billing unit
under this part that is a new billing unit (as defined
for purposes of paragraph (7)(B)) or that both complies
with the requirement of subsection (k)(4) for the
submission of information for a year (beginning with
2009) and meets (or is deemed to meet) performance
objectives applicable to the billing unit for the year
under subsection (k)(5), the update to the single
conversion factor established in paragraph (1)(C) for
the year shall be the percentage increase in the MEI
(as defined in section 1842(i)(3)) for the year
involved.
``(C) Treatment.--In computing the single
conversion factor under paragraph (1)(C) for 2010 or a
succeeding year, the updates for each preceding year
(beginning with 2009) shall be treated as the update
described in subparagraph (B).''.
(b) Establishment of Value-Based Purchasing Program.--Section 1848
of such Act is further amended by adding at the end the following new
subsection:
``(k) Value-Based Purchasing Program.--
``(1) Selection of quality and efficiency measures (q & e
measures).--
``(A) In general.--As part of the rulemaking
process for payments under this section for 2007, the
Secretary shall provide for the selection of quality
measures and efficiency measures (in this subsection
referred to as `Q-measures' and `E-measures',
respectively, or as `Q & E measures' collectively)
consistent with and in accordance with this paragraph
and paragraph (2).
``(B) Level of measurement.--Q-measures and E-
measures shall be measures that provide for assessment
of quality and efficiency, respectively, in the
provision of services to individuals enrolled under
this part at the level of a billing unit under this
part.
``(C) Characteristics of measures.--To the extent
feasible and practicable, Q & E measures shall--
``(i) include a mixture of outcome
measures, process measures (such as furnishing
a service), and structural measures (such as
the use of health information technology for
submission of measures);
``(ii) include efficiency measures related
to clinical care (such as overuse, misuse, or
underuse);
``(iii) include measures of care furnished
to frail individuals over the age of 75 and to
individuals with multiple complex chronic
conditions;
``(iv) be evidence-based, if pertaining to
clinical care;
``(v) be consistent, valid, practicable,
and not overly burdensome to collect;
``(vi) be relevant to physicians and other
practitioners, individuals enrolled under this
part, and the Federal Supplementary Medical
Insurance Trust Fund;
``(vii) include measures that, taken as a
whole, provide a balanced measure of
performance of a billing unit under this part;
``(viii) include measures that capture
individuals' assessment of clinical care
provided; and
``(ix) include measures that assess the
relative use of resources, services, or
expenditures.
``(D) Fairness.--To the extent feasible and
practicable, this subsection shall be implemented in a
manner that--
``(i) takes into account differences in
individual health status;
``(ii) takes into account individual's
compliance with orders;
``(iii) does not directly or indirectly
encourage patient selection or de-selection by
billing units under this part;
``(iv) reduces health disparities across
groups and areas; and
``(v) uses appropriate statistical
techniques to ensure valid results.
``(E) Application to non-physician practitioners
and other suppliers for which payment is made under or
in relation to physician fee schedule.--Insofar as
physicians' services under this section are furnished
by non-physician practitioner or a supplier other than
a physician--
``(i) any reference in this subsection to a
physician shall be a reference to such
practitioner or supplier; and
``(ii) any reference to a physician
specialty organization is deemed a reference to
a specialty organization representing the
speciality of such practitioners or suppliers.
``(2) Selection process for measures.--
``(A) Submission of proposed measures to consensus-
building organization.--
``(i) By physician specialty
organizations.--The Secretary shall request
each physician specialty organization to submit
to the consensus-building organization by March
1, 2006, proposed Q & E measures described in
clauses (i) through (vii) of paragraph (1)(C)
that would be applicable to clinical care that
billing units under this part practicing in the
specialty provide to individuals enrolled under
this part.
``(ii) By secretary.--If the physician
specialty organization for a physician
specialty has not submitted proposed Q & E
measures under clause (i) by March 1, 2006, the
Secretary shall submit, as soon as possible but
not later than April 1, 2006, proposed Q & E
measures described in clauses (i) through (vii)
of paragraph (1)(C) for such specialty to the
consensus-building organization.
``(iii) Consensus-building organization
defined.--For purposes of this paragraph, the
term `consensus-building organization' means an
organization, such as the National Quality
Forum, that the Secretary identifies as--
``(I) having experience in using a
process (such as the process described
in OMB circular A-119 published in the
Federal Register on February 10, 1998)
for reaching a group consensus with
respect to measures, such as Q & E
measures, relating to performance of
those providing health care services;
and
``(II) including in such process
representatives of the Secretary,
practicing physicians (and, as provided
under paragraph (1)(E), practicing non-
physician practitioners and other
suppliers), practitioners with
experience in the care of the frail
elderly and individuals with multiple
complex chronic conditions,
organizations and individuals
representative of the specialty
involved, individuals enrolled under
this part, experts in health care
quality and efficiency, and individuals
with experience in the delivery of
health care in urban, rural, and
frontier areas and to underserved
populations.
``(B) Recommendations by consensus-building
organization.--The consensus-building organization that
receives proposed measures under subparagraph (A) is
requested to submit to the Secretary by July 1, 2006,
recommendations respecting the Q & E measures described
in clauses (i) through (vii) of paragraph (1)(C) to be
implemented under this subsection.
``(C) Secretarial selection.--The Secretary shall
select Q & E measures described in paragraph (1)(C) for
purposes of this subsection consistent with the
following:
``(i) Use of recommendations for clinical
care measures submitted by certain
organizations.--Except as provided in clause
(ii), the Secretary shall not select a Q & E
measure described in clauses (i) through (vii)
of paragraph (1)(C) and relating to clinical
care unless that measure has been submitted by
a physician specialty organization (or through
a physician-consensus building process, such as
the Physician Consortium for Performance
Improvement) and recommended by the consensus-
building organization under subparagraph (B).
``(ii) Provision by regulation.--The
Secretary may by regulation select--
``(I) Q & E measures described in
clauses (i) through (vii) of paragraph
(1)(C) and relating to clinical care
that do not meet the requirements of
clause (i) only if the Secretary
determines that there were no, or
insufficient, recommendations regarding
such Q & E measures under such clause;
and
``(II) Q & E measures described in
clause (viii) or (ix) of paragraph
(1)(C) and Q & E measures described in
clause (i) through (vii) of such
paragraph that do not relate to
clinical care.
``(D) Periodic revision of selection.--The
Secretary shall provide for the periodic revision and
selection of Q & E measures consistent with the
provisions of this paragraph and paragraph (1) and the
application of such revised Q & E measures on a
prospective basis for a following year.
``(3) Ratings of physicians based on measures.--
``(A) Ratings and identification of quality
performance.--
``(i) In general.--The Secretary shall
determine a single rating of each billing unit
under this part based on Q & E measures
selected under paragraph (2) and information
reported under paragraph (4). Such a rating
shall be determined for a billing unit based on
its performance on Q & E measures relative to
the performance of its peers.
``(ii) No direct disclosure of rating.--
Subject to subparagraph (B), the Secretary
shall not make such ratings of identifiable
billing units under this part available other
than to the respective unit.
``(iii) Improvement and performance
thresholds.--For specification of improvement
and performance thresholds, see paragraph
(5)(D).
``(B) Disclosure of performance in relation to
performance thresholds.--
``(i) In general.--Subject to the
succeeding provisions of this subparagraph,
each year the Secretary shall make widely
available to the public the following
information regarding a billing unit's
performance on the Q & E measures:
``(I) Whether the unit was a new
billing unit or otherwise had
insufficient data to provide for a
measurement of whether it met the
performance objectives under paragraph
(5)(C).
``(II) For any other unit, whether
the unit met the performance objectives
under such paragraph.
``(ii) Limitation during first 2 years.--
During 2007 and 2008, the Secretary shall not
make the information under clause (i) with
respect to an identifiable billing unit
available other than to the respective unit.
``(iii) Physician notification and
opportunity for comment or appeal.--Before
making information under clause (i) available
with respect to a billing unit under this part
for years beginning with 2009, the Secretary
shall notify the unit of the performance on Q &
E measures (including information on the unit's
performance in relation to performance
objectives and aggregate information regarding
the performance of peers) and provide the
opportunity for the unit to provide written
comments regarding the unit's performance. The
Secretary shall respond in writing to the
comments and seek to reach agreement on the
unit's performance and shall establish a formal
appeals process in the event of continued
disagreement concerning such performance. Upon
conclusion of the appeals process, if the unit
provides comments relating directly to the
final determination under clause (i) respecting
such performance, the Secretary shall disclose
such comments with the disclosure of the
information under such clause.
``(iv) Application of hipaa privacy
rules.--Nothing in this subparagraph shall be
construed as changing or affecting the
application of rules promulgated under section
264(c) of the Health Insurance Portability and
Accountability Act of 1996.
``(C) Peers defined.--For purposes of this
subsection, the term `peers' means, with respect to a
billing unit under this part that practices in a
specialty in an MA region (as established under section
1858(a)(2)), other billing units under this part that
practice in the same specialty in the same region, or,
beginning with the update for 2012, or in the United
States.
``(4) Reporting on performance beginning with 2007.--For
purposes of, and in order to be provided a higher update under,
subsection (d)(7) beginning with 2007, each billing unit under
this part may submit information on performance on the Q & E
measures selected under this subsection with respect to
individuals enrolled under this part. Such information shall be
submitted in a form and manner and time specified by the
Secretary, which may include submission as part of claims data
under this part. The Secretary shall provide a process for
auditing the accuracy of the information submitted under this
paragraph.
``(5) Incentives based on performance beginning with
2009.--
``(A) In general.--For purposes of, and in order to
be provided an increased update under, subsection
(d)(7) for 2009 and each subsequent year and for
purposes of disclosure under paragraph (3)(B), the
Secretary shall establish quality and efficiency
performance objectives for billing units under this
part.
``(B) Increased update.--For purposes of subsection
(d)(7), such a billing unit is considered to meet
performance objectives for a year if, based on ratings
under paragraph (3)--
``(i) the unit has demonstrated clear
improvement (as determined in accordance with
improvement standards specified by the
Secretary under subparagraph (D)) in
performance from its performance in the
previous year; or
``(ii) the unit's performance meets or
exceeds the performance thresholds specified by
the Secretary under subparagraph (D).
``(C) Disclosure.--For purposes of paragraph
(3)(B), such a billing unit is considered to meet
performance objectives for a year if, based on the
unit's rating under paragraph (3)(A), the unit's
performance meets or exceeds the performance thresholds
specified by the Secretary under subparagraph (D).
``(D) Improvement standards and performance
thresholds.--The Secretary shall specify improvement
standards under subparagraph (B)(i) and the performance
thresholds under subparagraphs (B)(ii) and (C) before
the beginning of the year involved.
``(E) Treatment of cases of insufficient
information.--A billing unit is deemed to meet
performance objectives under subparagraphs (B) and (C)
if the unit complied with the reporting requirement
under paragraph (4) but there was insufficient
information, as determined by the Secretary, to provide
a valid measure of performance.
``(6) Review of additional expenses.--Not later than May 1,
2008, and after consultation with the medical community, the
Secretary shall review, and report to Congress on, the extent
to which billing unit compliance with the reporting provisions
of paragraph (4) results in increased work and practice
expenses to billing units.
``(7) Physician and beneficiary education.--During 2006,
the Secretary shall establish a program to educate billing
units under this part and individuals enrolled under this part
about the value-based purchasing program under this subsection,
including information regarding financial incentives for
reporting information on Q & E measures and, beginning in 2009,
financial incentives based on performance on such measures.
``(8) Annual report on growth in volume of physicians'
services.--
``(A) In general.--The Secretary shall report to
the Medicare Payment Advisory Commission and Congress
by April 1 of each year (beginning with 2006)
information on the growth in volume of services per
enrollee and growth in expenditures per enrollee, based
upon services and expenditures for which payment is
based, or related to, the fee schedule established
under this section.
``(B) Details.--The information under subparagraph
(A) shall--
``(i) be disaggregated by type of service,
by geographic area, and by specialty of
physicians (or, if applicable, of non-physician
practitioners or suppliers);
``(ii) distinguish between growth in
expenditures due to price change versus volume
change and intensity change; and
``(iii) identify types of service or
geographic areas where changes in volume or
expenditures are inappropriate or unjustified,
taking into account clinical outcomes.
``(C) Recommendations.--Each such report shall
include recommendations to respond to inappropriate
growth in service volume. Such recommendations may
include regulatory or legislative changes, or both.
``(D) Medpac response.--The Medicare Payment
Advisory Committee shall review each report submitted
under this paragraph, including recommendations
included under subparagraph (C). The Commission shall
include in its report to Congress in June following
such report an analysis of the Secretary's findings and
recommendations.
``(9) Evaluation; report.--
``(A) Evaluation.--The Secretary shall provide for
an evaluation of the operation of this subsection
during the 5-year period in which this subsection is
first applied. Such evaluation shall review the impact
of this subsection on improving the quality and
efficiency of services and on access to such services
and on the fairness of its implementation.
``(B) Report.--The Secretary shall submit to
Congress a report on such evaluation by not later than
September 30, 2011.
``(10) Waiver of administrative and judicial review.--There
shall be no administrative or judicial review under section
1869 or otherwise of--
``(A) the selection of Q & E measures under
paragraphs (1) and (2);
``(B) the development and computation of ratings
under paragraph (3)(A), standards and thresholds under
paragraph (5)(D), and the application of such standards
and thresholds under paragraphs (3)(B), (5)(B), and
(5)(C); and
``(C) the definition of peers and new billing units
under this subsection.''.
(c) Ending Application of Sustainable Growth Rate (SGR).--Section
1848(f)(1)(B) of such Act (42 U.S.C. 1395w-4(f)(1)(B)) is amended by
inserting ``(and before 2005)'' after ``each succeeding year''.
(d) Conforming MedPAC Duties.--Section 1805(b)(2) of such Act (42
U.S.C. 1395b-6(b)(2)) is amended by adding at the end the following new
subparagraph:
``(D) Review of report on growth in physician
services.--Specifically, under section 1848(k)(8)(D),
the Commission shall review and make recommendations
concerning the Secretary's report on the growth of
physicians' services under section 1848.''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health.
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